Fundamentals of Nursing Exam Study Guide : Updated Solution: Questions & Answers, Exams of Nursing

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Fundamentals of Nursing Exam Study

Guide

pulse is regulated by what? (Ans- autonomic nervous system through cardiac sinoatrial node parasympathetic stimulation on pulse (Ans- decreases heart rate sympathetic stimulation on pulse (Ans- increases heart rate pulse rate (Ans- the number of contractions over a peripheral artery in 1 minute places you can record a pulse (Ans- temporal, carotid, brachial, radial, femoral, popliteal, posterior tibial, dorsalis pedis pulmonary ventilation (Ans- movement of air in and out of lungs diffusion (Ans- exchange of oxygen and carbon dioxide between the alveoli of lungs and circulating blood Perfusion (Ans- exchange of oxygen and carbon dioxide between circulating blood and tissue cells eupnea (Ans- normal, unlabored breathing, one respiration to four heartbeats

tachypnea (Ans- increased respiratory rate; may occur in response to increased metabolic rate Bradypnea (Ans- decreased respiratory rate; occurs in some pathologic conditions Apnea (Ans- periods when no breathing occurs Dyspnea (Ans- difficult or labored breathing orthopnea (Ans- changes in breathing when sitting or standing assessing blood pressure (Ans-

• listening for Korotkoff sounds w/ stethoscope
• first sound is systolic
• change or cessation of sound occurs: diastolic pressure
• brachial artery and popliteal artery are commonly used major classifications of hypertension (Ans-
• primary (essential): characterized by an increase above normal in both systolic and diastolic pressures
• secondary : caused by another disease condition like kidney disease, aorta disorders, or adrenal cortex disorders Diuretics (Ans- used to increase urinary output

intentional wound (Ans- the result of planned invasive therapy or treatment ex. surgery, intravenous procedure unintentional wound (Ans- are accidental; occur from unexpected trauma open wound (Ans- occurs from intentional and unintentional trauma; skin surface is broken, providing a portal of entry for microorganisms closed wound (Ans- results from a blow, force, or strain caused by trauma such as a fall, an assault, or motor vehicle crash acute wound (Ans- usually heal within days to weeks chronic wound (Ans- do not progress through stages of healing; healing impeded albumin normal lab values (Ans- 3.5- 5 vitamin c and zinc (Ans- important in wound healing phases of wound healing (Ans-

• hemostasis-vessels constrict and clotting begins
• inflammatory-white blood cells move to wound
• proliferation-granulation tissue is formed
• maturation-collagen is remodeled, forms scar

Hemostasis (Ans- occurs immediately after initial injury, blood vessels constrict and clotting begins, exudate(drainage) forms and causes swelling and pain, increased perfusion results in heat and redness, platelets stimulate other cells to migrate to injury to participate in phases of healing inflammatory phase (Ans- follows hemostasis and lasts 4-6 days, white blood cells move to wound, macrophages enter wound and remain extended time, they ingest debris and release growth factors, pt has generalized body response proliferation phase (Ans- begins 2-3 days of injury and may last up to 2-3 weeks, new tissue is built to fill wound space through action of fibroblasts, capillaries grow across wound, thin layer of epithelial cells form across wound, granulation tissue forms a foundation for scar tissue to develop maturation phase (Ans- final stage of healing, begins 3 weeks to 6 months after injury, collagen remodeled, new collagen tissue is deposited, scar becomes thin white line desiccation (Ans- dehydration origination of the word "nurse" (Ans- from the latin word "nutrix" meaning to nourish Interrelated roles of nurses (Ans- communicator, teacher, counselor, leader, researcher, advocate, collaborator coping with disability and death

(Ans- defined nursing as both an art and science, differentiated nursing from medicine, created freestanding nursing education, published books; founder of modern nursing Clara Barton (Ans- established red cross; volunteered to care for wounds and feed union soldiers during civil war; served as supervisor of nurses for the army of James sources of knowledge (Ans- - traditional (passed down from generation to generation)

• authoritative- comes from an expert, accepted as truth based on person's perceived expertise
• scientific (obtained through the scientific method-research) objective (Ans- you can see the object Subjective (Ans- coming from that subject types of knowledge (Ans- - science (observing, identifying, describing, investigating, and explaining events and occurences that are perceived in world)
• philosophy (the study of wisdom, fundamental knowledge, and the processes used to develop and construct on perception on life)
• process (a series of actions, changes, or functions intended to bring about a desired result) goals of nursing research (Ans-
• improve care in clinical setting
• study ppl and nurse process: education, policy development, ethics, nursing history
• develop greater autonomy and strength as a profession

• provide evidence-based nursing practice deductive reasoning (Ans- examines a general idea and then considers specific actions or ideas inductive reasoning (Ans- one builds from specific ideas or actions to conclusions about general ideas health (Ans- a state of complete physical, mental, and social well-being, not merely the absence of disease or infirmity illness (Ans- the unique response of a person to a disease; an abnormal process involving changed level of functioning wellness (Ans- an active state of being healthy by living a lifestyle promoting good physical, mental, and emotional health nursing theory (Ans- differentiates nursing from other disciplines and activities in that it serves the purposes of describing, explaining, predicting, and controlling desired outcomes of nursing care practices evidence-based practice (EBP) (Ans- a problem-solving approach to making clinical decisions, using the best evidence available; blends both science and art of nursing so best outcomes are achieved; may consist of specific nursing interventions or use guidelines established for the care of patients

(Ans- focus on SCREENING for early detection of disease with prompt diagnosis and treatment of any found; example: assessing children for normal growth and development and encourage regular medical, dental and vision exams tertiary health promotion (Ans- after an illness is diagnosed and treated; example: teaching a patient with diabetes how to recognize and prevent complications, refer woman to support group after removal of breast due to cancer maslow hierarchy of needs (Ans- provides a framework for nursing assessment and for understanding the needs of patients at all levels; many nursing interventions are aimed at meeting patients' basic human needs Maslows level 1: physiologic needs (Ans- oxygen, food, water, sex, rest, physical activity; physiologic needs are highest priority Maslows level 2: safety and security needs (Ans- both physical and emotional components; being protected from potential or actual harm Maslows level 3: love and belonging needs (Ans- often called higher-level needs; understanding and acceptance of others in both giving and receiving love; feeling of belonging; unmet needs produce loneliness and isolation Maslows level 4: self-esteem needs (Ans- need for a person to feel good about oneself, to feel pride and a sense of accomplishment, and to believe that others also respect and appreciate those accomplishments; positive self-esteem facilitates the person's confidence and independence

Maslows level 5: Self-Actualization (Ans- acceptance of self and others as they are; each lower level must be met; focus of interest on problems outside oneself; respect for all people; focus on strengths and possibilities vs problems autonomy (Ans- respect rights of patients to make health care decisions Nonmaleficence (Ans- avoid causing harm Beneficence (Ans- benefit the patient; balance benefits against risks and harms nurse practice acts (Ans- each state has its own; protects public with legal scope of nursing practice standards (Ans- used as guidelines for peer review (ANA) establishing an effective nurse-patient relationship (Ans-

• reduce anxiety through therapeutic communication, teaching, and acceptance
• remember that the patient has concerns and needs other medical ones
• communicate with the patient as an individual
• take time to learn about the patient being admitted
• provide for the family participation in all aspects of care when does discharge planning start? (Ans- as soon as the patient comes in the door oral temperature for healthy adult (Ans- 37.0 C, 98.6 F

heat production (Ans-

• primary source is metabolism
• hormones, muscle movements, exercise increase metabolism
• thyroid hormone and shivering also increase heat production
• energy production decreases and heat production increases sources of heat loss (Ans- skin (primary source), evaporation of sweat, warming and humidifying inspired air, eliminating urine and feces radiation (Ans- diffusion of heat by electromagnetic waves (such as an uncovered head) factors affecting body temp (Ans-
• circadian rhythms
• age and gender
• physical activity
• state of health
• environmental temperature Maceration (Ans- overhydration Trauma (Ans- physical injury edema (Ans- swelling caused by excess fluid trapped in your body's tissues necrosis

(Ans- death of tissue wound complications (Ans-

• infection
• hemorrhage
• dehiscence(wound separates) and evisceration(protrusion)
• fistula formation Dehiscence (Ans- Bursting open of a wound, especially a surgical abdominal wound stages of pressure ulcers (Ans-
• stage1: nonblanchable erythema of intact skin
• stage2: partial-thickness skin loss
• stage3: full-thickness skin loss; not involving underlying fascia( epidermis and dermis)
• stage4: full-thickness skin loss with extensive destruction (epidermis, dermis, and subcutaneous)
• unstageable: base of ulcer covered by slough and/or eschar in wound bed measurement of pressure ulcer (Ans- - size of wound
• depth of wound
• presence of undermining, tunneling, or sinus tract(all on wound bed) when measuring a wound (Ans- measure from left to right and then top to bottom friction (Ans- occurs when two surfaces rub against each other shear (Ans- results when one layer of tissue slides over another layer pressure ulcer (Ans- wound with localized area of injury to the skin and/or underlying tissue

pain tolerance (Ans- the maximum level of pain that a person is able to tolerate acute pain (Ans- rapid in onset, varies in intensity and duration, protective in nature chronic pain (Ans- pain that may be limited, intermittent, or persistent but that lasts beyond the normal healing period physiological measures that indicate pain (Ans- increased blood pressure and pulse meaning of healing (Ans- mending and getting better from disease 6 classes of nutrients (Ans- supply energy: carbs, proteins, lipids regulate body processes: vitamins, minerals, water carbs (Ans- - sugars and starches

• organic compounds composed of carbon, hydrogen, and oxygen
• lactose is an animal source
• most abundant and least expensive
• classified as simple or complex sugars
• converted to glucose for transport through blood
• 50 - 100g needed daily to prevent ketosis protein (Ans- - required for formation of all body structures
• based on amino acid composition
• animal proteins are complete, plant proteins are incomplete
• RDA for adults is 0.8g/kg fats (Ans- - insoluble in water and blood
• composed of carbon, hydrogen, and oxygen
• 95% of lipids in diet are triglycerides
• most animal fats are saturated
• most vegetable fats are unsaturated

• digestion occurs largely in small intestine
• most concentrated source of energy in diet
• RDA not established, 20-35% total calorie intake Vitamins (Ans- - organic compounds needed by the body in small amounts
• most are active in form of coenzymes
• classified as water soluble or fat soluble
• absorbed through intestinal wall (small intestine) directly into bloodstream
• needed for metabolism minerals (Ans- - inorganic elements found in all body fluids and tissues
• some function to provide structure in the body, others help regulate body processes
• contained in ash that remains after digestion
• macro minerals include calcium, phosphorus, magnesium
• microminerals include iron, zinc, manganese, and iodine water (Ans- - accounts for between 50% and 60% of adults total weight
• 2/3 of body water is contained within the cells (ICF)
• the remainder of body water is extracellular fluid, body fluids
• acts as solvent, aids digestion pronation (Ans- face down; laying on your stomach supination (Ans- face up; laying on your back (spine) inversion (Ans- turning foot inward eversion (Ans- turning foot outward afferent nervous system conveys info to the (Ans- CNS; going to your brain efferent (Ans- creates effect and goes to body part from brain the efferent system conveys via (Ans- somatic nervous system

frequency (Ans- increased incidence of voiding glycosuria (Ans- presence of sugar in the urine nocturia (Ans- awakening at night to urinate oliguria (Ans- scanty or greatly diminished amount of urine voided in a given time; 24-hour urine output is less than 400mL polyuria (Ans- excessive output of urine (diuresis) proteinurea (Ans- protein in the urine; indication of kidney disease pyuria (Ans- pus in the urine; urine appears cloudy suppression (Ans- stoppage of urine production; normally, the adult kidneys produce urine continuously at the rate of 60 to 120 mL/h urgency (Ans- strong desire to void urinary incontinence (Ans- involuntary loss of urine overflow incontinence (Ans- chronic retention of urine, the involuntary loss of urine associated functional incontinence (Ans- urine loss caused by the inability to reach the toilet because of environmental barriers, physical limitations, loss of memory, or disorientation reflex incontinence (Ans- experience emptying of the bladder w/o sensation of the need to void total incontinence (Ans- a continuous and unpredictable loss of urine, resulting from surgery, trauma, or physical malformation

dialysis (Ans- a mechanical way of filtering waste from the blood nursing process for bowels (Ans- - inspection

• auscultation
• percussion
• palpation (deep palpation is performed by advanced medical personal) when listening to bowel sounds (Ans- start lower right and go up, across and down occult blood in stool (Ans- blood that is hidden in the specimen or cannot be seen on gross examination direct studies (Ans- going inside the body ex. colonoscopy, sigmoidoscopy indirect studies (Ans- commonly performed through radiography ex. abdominal ultrasound, MRI, abdominal CT scan, small bowel series, barium enema constipation (Ans- dry, hard stool; persistently difficult passage of stool; incomplete passage of stool laxatives (Ans- drugs that induce emptying of the intestinal tract enema (Ans- the introduction of a solution into the large intestine, usually to remove feces suppository (Ans- a conical or oval solid substance shaped for easy insertion into a body cavity and designed to melt at body temperature ileostomy (Ans- allows liquid fecal content from the ileum of the small intestine to be eliminated through the stoma colostomy (Ans- permits formed feces in the colon to exit through the stoma